Dr. Aw: Should we retire the handshake to help stop the spread of deadly infections?

What’s in a handshake? Turns out, quite a lot, actually. And more than we might want.

At first I dismissed it as one of those oddball things that turns up sometimes in medical journals. Published earlier this month in the Journal of the American Medical Association, the piece proposed the idea that hospitals and health clinics ban traditional handshakes because of the “infectious risk” involved in being part of one.

After more than 40 years of study, the U.S. government said Monday it has no evidence that the antibacterial chemicals used in countless common soaps and washes help prevent the spread of germs, and it is reviewing research suggesting they may pose health risks.

Regulators at the U.S. Food and Drug Administration said they are revisiting the safety of chemicals such as triclosan in light of recent studies that suggest the substances can interfere with hormone levels and spur the growth of drug-resistant bacteria.

The U.S. government’s preliminary ruling lends new support to outside researchers who have long argued that the chemicals are, at best, ineffective and at worst, a threat to public health.

“The FDA is finally making a judgment call here and asking industry to show us that these products are better than soap and water, and the data don’t substantiate that,” said Stuart Levy of Tufts University School of Medicine.

“Multiple studies have demonstrated that the handshake can and does transmit pathogens,” wrote Dr. Mark Sklansky and his colleagues, all of whom are affiliated with medical programs at University of California, Los Angeles.

“Oh sure,” went my knee-jerk reaction. “Breathing also transmits pathogens — and are we going to ban that, too? And what’s next? A suggestion that we only go outside in astronaut suits?”

But then, later in May came the event that prompted me to take the notion more seriously. The U.S. Centers for Disease Control and Prevention (CDC) released news about an alarming new virus known best by its already widespread acronym, MERS, which stands for Middle East Respiratory Syndrome. MERS, like SARS, is a coronavirus that comes on with symptoms similar to the common cold or the flu. But it’s a lot more lethal, with 30% of cases ending in death.

The CDC said it had identified the first confirmed case in North America of a person-to-person transmission of the virus. Because CDC is trying to secure the anonymity of the people involved, we just know the case’s broad outlines. Just before an Indiana man had tested positive for MERS, it seems, he’d had a business meeting with a guy from Illinois who subsequently caught the virus. Among the things implicated in the possible transmission of the virus? The fact that the two men had shaken hands.

So let’s take another look at the case for banning handshakes from health care settings.

One of my good friends and mentors gave up the practice about a decade ago after living through Toronto’s SARS crisis. Now, when I see him, sometimes I’ll forget and step forward with my hand extended, and he just smiles and waves. “The SARS wave,” he calls it, with a self-awareness that turns out to be charming.

I’ve long been a big proponent of the handshake. It lets a patient know that what they’re about to say is important

In contrast, I’ve long been a big proponent of the handshake. Conducted at the beginning and end of an appointment, a handshake places the patient and the doctor on a plane of mutual respect. The practice lets a patient know that what they’re about to say is important — and that I’m here to listen. And Sklansky and his co-authors also acknowledge the importance of the tradition to the doctor-patient relationship.

“Handshakes between health care practitioners and their patients have the potential to comfort and to calm,” Sklansky says.

But is a handshake necessary to establish this footing? Or could some other element of ritualistic behaviour establish a similar relationship between patient and doc? According to a 2013 study cited by Sklansky et al., “80% of individuals retain some disease-causing bacteria after washing.” The study suggested that a “fist bump,” which sees participants touch knuckles, has the potential to transmit fewer germs, because the flesh-to-flesh contact is less, and shorter in duration.

Covering a sneeze with a hand is now considered impolite in many circles

Other options suggested by Sklansky include bowing, which “symbolizes reverence and respect.” Then there’s the gesture that accompanies the South Asian greeting of namaste — placing palms together at the chest, and inclining slightly at the waist. And a third option the L.A. doctors discuss is the Muslim-inflected “salaam” gesture that sees the right palm placed over the heart, again with a subtle bow.

The transmission of germs has already triggered incremental changes in public behaviour. Once, our parents admonished us to “cover our mouths” when we sneezed — and most people of my generation did that with the palms of their hands. But then everyone realized that this practice still spread a lot of germs — because those sneezed-on hands, now germ-ridden, went on to touch doorhandles and escalator railings. So public health officials developed the “sleeve sneeze” — and now covering a sneeze with a hand is considered impolite in many circles. Over and above that, health-care administrators always are working to improve handwashing compliance from front-line healthcare staff.

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So is it time to retire the handshake? Ten years from now, will young people regard older folks who still shake hands as pariahs? Sklansky suggests a public health campaign that includes signs at health-care settings such as hospitals: “Handshake-free zone: to protect your health and the health of those around you, please refrain from shaking hands while on these premises.”

While MERS stays relatively contained, I’m going to keep pressing the flesh. But I’m open to the possibility that the handshake’s days are numbered, too.

—Dr. James Aw is the medical director of the Medcan Clinic, a leading private health clinic in Toronto. For more information, visit medcan.com.